Integrating the Chronic Care Model in the Management of Obesity In an Inner City Population

In 2006, Thomas Jefferson University created a Center for Excellence in Obesity Research, involving multiple Academic and Clinical Departments, community organizations and the Philadelphia Department of Public Health. The health services research component of the Center is the Clinic Community Intervention Program (CCIP), which uses Wagner's Chronic Care Model (CCM) to provide a framework for integrating support for obese patients (BMI>30) aged 18-45 to engage in healthy lifestyles with a clinical care model that improves provider identification and management of obesity, hypertension, dyslipidemia, and other obesity-related co-morbidities. The CCIP target population is from inner city neighborhoods and predominantly African American and Hispanic. In the CCIP's application of the CCM, the patient support component includes a clinic based Lifestyle Counselor, and linkage to an 8 session skills based curriculum that is community based and includes programs designed to assist study patients to develop healthy lifestyles through improvements in diet, physical activity, stress management and planned exercise. These sessions are held in neighborhoods of patient origin. The CCIP uses the CCM as a framework for obesity management by conducting provider education and performance monitoring (using NHLBI Obesity Management Guidelines), providing self-management support, and linking participants to community based resources and programs. Two health care teams were created, one in the Philadelphia Department of Public Health (PDPH) - Health Center #6 and the other within Jefferson Family Medicine Associates (JFMA). Each team includes Primary Care Providers, a Lifestyle Counselor, and a Community Health Educator. To facilitate optimal function of these teams, training was provided to all site personnel who are directly involved with patients. Communication is ongoing between the providers, Lifestyle Counselor and Health Educator. Assessment measures, performed at baseline and at intervals, include a lipid profile, glucose, and chemistry panel; height, weight, BMI; Perceived Stress Scale; Readiness to Change; Physical Activity level (using the International Physical Activity Questionnaire); semi-quantitative food frequency questionnaire; nutrition/weight loss knowledge, attitudes and behaviors and self-efficacy. Start-up and logistical issues, as well as process and outcome measures to date, will be presented.